Provider Demographics
NPI:1952461030
Name:ANDERSON, VICKI LEATRICE (MD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:LEATRICE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:PHYSICAL MEDICINE AND REHABILITATION
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-7342
Mailing Address - Fax:414-805-7348
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:PHYSICAL MEDICINE AND REHABILITATION
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-7342
Practice Address - Fax:414-805-7348
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-08-31
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-09
Provider Licenses
StateLicense IDTaxonomies
WI49963208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1952461030Medicaid
WI736011391Medicare PIN